Psychotropic Medications




INTRODUCTION



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Chronic pain is frequently comorbid with both anxiety and mood disorders. Although many pain medicine practitioners may not manage psychiatric conditions, it is increasingly important to have at least a rudimentary familiarity with first-line psychiatric medications used to treat anxiety and mood disorders, a class of medications that is commonly encountered by pain specialists.



The mnemonic AMPS, or anxiety, mood, psychosis, and substance abuse, can be used to describe which psychiatric conditions are more commonly seen in the outpatient setting. In this chapter, we focus on the medication management of anxiety and mood (including major depressive disorder and bipolar spectrum disorders) because these disorders often influence the short- and long-term prognosis of those with chronic and unexplained pain. Antipsychotic medications are also discussed because there is much overlap with this class and the treatment of bipolar disorder. Tables 76-1 and 76-2 provide a practical overview of these medications.




TABLE 76-1

Overview of the First-Line Antidepressants






TABLE 76-2

Overview of the Mood Stabilizers





The following list illustrates the importance of including evidence-based psychiatric screening strategies and initiating timely and effective treatment for patients with depression and anxiety, within the context of providing care for those who have a severe or refractory pain condition(s).





  • At least one-half of all those referred for outpatient mental health care do not connect with a mental health provider. There are many reasons for this, including poor access to care and mental health–related stigma.1



  • Treatments of anxiety and mood disorders relieve “mental pain” and often have a therapeutic effect on “physical pain” disorders.



  • Some psychotropic medications are used as to treat primary pain conditions (e.g., norepinephrine reuptake inhibitors). A complete understanding of the indications for use, mechanism of action, and possible side effects is critical for pain medicine practitioners.2



  • The combination of severe and chronic pain, coupled with untreated depression and anxiety, can result in significant disability or possibly suicide. About one-half of all those who complete suicide have seen their non–mental health, medical provider 30 days before their death. About one-half of these cases result in litigation.3





ANTIDEPRESSANTS



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SELECTIVE SEROTONIN REUPTAKE INHIBITORS/SEROTONIN ANTAGONIST AND REUPTAKE INHIBITORS



Indications


The selective serotonin reuptake inhibitors (SSRIs) were developed in the 1980s and saw an explosion of use as safe, well tolerated, and effective treatments for depression. Now the SSRIs are indicated for a wide range of depressive and anxiety disorders, including major depression, obsessive-compulsive disorder (OCD), panic disorder, generalized anxiety disorder (GAD), posttraumatic stress disorder (PTSD), social phobia, premenstrual dysphoric disorder, and bulimia nervosa. Since the introduction of Prozac in 1987, antidepressant prescribing has quadrupled, and antidepressants have become the third most commonly prescribed class of medications among Americans and the most commonly prescribed class among Americans aged 18 to 44 years. Psychiatrists prescribe less than one-third of these medications. Depression occurs comorbid with chronic pain in up to 60% of patients and can complicate the treatment and worsen the prognosis of pain. On the other hand, the successful treatment of depression can reduce pain perception. The safety and tolerability of the SSRIs make them an important tool for the pain practitioner.



Regardless of the drug, medication therapy is effective in the majority of moderate to severe cases of depression. Within approximately 6 weeks, one-half of persons receiving antidepressants have at least a 50% reduction in symptoms.4 In the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study, 30% of patients achieved full remission after 12 weeks of treatment with citalopram, and 10% to 15% more showed significant improvement. One-quarter of patients who failed citalopram responded when switched to sertraline, venlafaxine, or bupropion. A similar number responded when bupropion was added to citalopram.5 Benefits of antidepressant therapy may take as little as 1 week or as long as 6 to 8 weeks to see. Unless intolerable, medications should not be changed or discontinued in the first 6 weeks of therapy for depression or anxiety (see Table 76-1).

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Jan 10, 2019 | Posted by in PAIN MEDICINE | Comments Off on Psychotropic Medications

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